17A-212 0 0
(rzfy of Warthamptan
y Z
� � �1'iiassachusetfs I`'
DEPARTMENT OF BUILDrNTG INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building '>ow
North.vnpton,MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as hlis/her construction supe: .-;;or. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or two family
dwelling, attached or detached structures accessory to such use and/or farm structures. A
person who constructs more than one home in a two-year period shall not be considered a
home owner."
The building department for the City of Northampton wants any person(s) who seek to
use the home owner exemption, to act as their own construction supervisor, to be aware
that by doing so you become responsible for compliance with state building codes
and regulations. The inspection process requires that the building department be called
to inspect work at various stages, which include foundation/footings (before backfill),
sonotube holes (before pour), a rough building inspection (before work is
concealed), insulation inspection (if required) and a final building inspection. The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades to perform work(electrical, plumbing& gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
permits in conjunction to the building permit issued, and that they get their required
inspections. Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
I, understand the above.
(Home owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date
Address of work
location
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers
Applicant Information Please Print Le E01
Name(Business/Organization/Individual): L/6 7,7 /
Address: 12 2 L"/C 7 / �-
City/State/Zip: (� � (�t/ i _10 Phone.#: 5 5 / 7
Are you an employer?Check the appropriate boa: Type of project(required):
4. I am a general contractor and I
1.❑ I am a employer with � New construction
employees(full and/or part-time).* have hired the sub-contractors 6. ❑
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. FI Remodeling
ship and have no employees These sub-contractors have 8. Fj Demohuon
working for me in any capacity. employees and have workers'
9. � Building addition
[No workers' comp.insurance comp.insurance.
T
required.] 5. We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I LEJ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs
insurance required t_--___- _-__-- —_c. 152, §1(4),and we have no _ __
employees. [No workers' O
13. ther
comp.insurance required.]
*A-vap-plicant that checics box# must also fill out the section below-showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins. Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage,as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1;500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a file
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under thepains andpenaltieslties o�that the information provided above is true and correct.
Simature: ' Date: _
Phone#:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
SECTION-8—CONSTRUCTION SERVICES
8.1 Licensed Construction S9u ervisor: Not Ap licca''b�le ❑
Name of license Holder: V/ ,IT// 1) !` /Y_ ✓j'
License Number
Address Expiration Date
Sig ture Telephone
Not Applicable ❑
9.Re i "tieireil dome-lm'coveinent�ontractQr.= ... _,. .,, „� �,w �., ,._ PP
Corhnafiv Name RegistratioT1umber
e
Address. Expir ton Date
LICI �G '` - l Telephone g 2-
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§-25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
11. :Hone Uwner.�xemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
as supervisor.CMR 780. Sixth Edition Section 108.3.5.1.
Definition of Homeowner:Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there
is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm
structures.A person who constructs more than one home in a two-vear period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the buildine permit.
As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152(Workers'Compensation) and Chapter 153(Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) o Roofing ED
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding ]_Other[[I
Brief Descript' n of Proposed / �?
Work: -I,'_ /,�n F ILJ��!"et Y r, j{-1 6I/L✓7
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa if New---tiouse-and or`addition to ezisting houslng,complete..the follovirltno
a. Use of building:One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c_ Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
I. Is construction within 100 ft.of wetlands? Yes No. is construction within 100 yr. floodplain ies - No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
I. Septic Tank City Sewer Private well City water Supply
SEGTION 7a-OWNER:AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
r-
1 as Owner of the subject
property
hereby authorize
to act o .my behalf,in matterMlative to work authorized by this building permit application.
/ c
Signature of Owne Date
as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name
Signature of Owner/Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location) IL
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
_
NO G --' . —'-- `~' .-_
IF YES, date hsue
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES 0
IF YES: enter Book Pa and/or Douument#
�� ��
D. Does the site contain o brook, body of water urwetlands? NO «���� DON7KNUVV �~� YES �~�
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs tobeobtuioed '
�-\ Obta[ned �~\ Da�e Issued:
v~� �~� ' � .
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions ofsigns intended for the pruperty? YES NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre orish part ofa common plan
that will disturb over 1acre? YEO ���l NO ���l
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
µ� Depafinentasevnty
Gity of Northampton
Statu efttti ..
� � ���� �"
�u'tiding Department tfvewa PJet
012 Main Street e
Room 100ela
North, mpton, MA 01060MoP`ans � � �
phone 2113-587-�240 Fax 413-587-1272
APPLICA CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION -SITE.INFORMATION
1.1 Pro ert Address:
This section to be completed byoffice ,
Map "Lot Unrt
one Overlay Disfrict,-
,.Elm 5t.Distract CS District .
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owne of Record:
e(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature /telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS �2 r c-'C%. oc
Item Estimated Cost(Dollars)to We Official Use Only
completed by ermit applicant
1. Building (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost-of
Construction'from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For OfFicial-Use Only
Building Permit Number. Date
Issued:
Signature:
Building Commissioner/inspector of Buildings Date
BP-2008-0061
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2008-0061
Project# JS-2008-000089
Est. Cost. $2000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Ronald Mistarka 118693
Lot Size(sg. ft.): 25918.20 Owner: SZAWLOWSKI JOHN R&DORIS E
Zoning:URB Applicant: Ronald Mistarka
AT. 126 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
122 WEST ST (413) 575-1271
WEST HATFIELDMA01088-0519 ISSUED ON.711812007 0:00:00
TO PERFORM THE FOLLOWING WORK.-RESIDE REAR OF BARN
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType• Date Paid: Amount:_
Building 7/18/2007 0:00:00 $25.003162
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo